cdc-ehr-mu--ph-virtual-event_transcription

Electronic Health Records Meaningful Use & Public Health Virtual Event December 18, 2012 AGENDA Time Session Title 12:00pm – 1:00pm EHR MU: What is in it for Public Health? 1:00pm – 2:30pm EHR MU & PH: The Local Implementation Perspective 2:30pm – 3:30pm EHR MU: Past, Present, & Future 3:30pm – 4:30pm EHR MU & PH Data Exchange: Implications & Challenges 4:30pm – 5:30pm EHR MU & PH: Getting Ready for Stage Meaningful Use Presenter Dr Art Davidson, MD, MSPH Director of Public Health Informatics Denver Public Health Denver, CO Jeffrey Johnson Senior Epidemiologist County of San Diego San Diego, CA Robert Wester Manager of San Diego Immunization Registry County of San Diego San Diego, CA Michael Coletta, MPH Lead Informatics Analyst National Association of County and City Health Officials (NACCHO) Washington DC Travis Broome, MBA, MPH Lead Health Insurance Specialist & Policy Lead Centers for Medicare & Medicaid Services (CMS) Dallas, TX Jim Daniel, MPH Public Health Coordinator Office of the National Coordinator (ONC) Washington DC Jim Kirkwood, MPH Senior Director, eHealth Association of State & Territorial Health Associations (ASTHO) Arlington, VA Dr Bryant Thomas Karras, MD Senior Epidemiologist, Chief PH Informatics Officer State of Washington Department of Health Seattle, WA Page of 62 Table of Contents Introduction Review of Agenda What is in it for Public Health? - Dr Arthur Davidson Q&A 13 The Local Implementation Perspective – Part – Jeffrey Johnson 15 The Local Implementation Perspective – Part – Robert Wester 18 The Local Implementation Perspective – Part – Michael Coletta 22 Q&A 24 EHR MU Past, Present, & Future – Travis Broome 26 Q&A 35 EHR MU & PH Data Exchange: Implications & Challenges – Jim Daniel 39 Q&A 49 EHR MU & PH: Getting Ready for Stage Meaningful Use - Jim Kirkwood & Dr Bryant Karras 50 Q&A 57 Concluding Remarks 62 CDC Event Coordinators 62 Page of 62 Introduction Good afternoon to all of you on the East Coast and good morning to our friends on the West Coast Welcome to the Electronic Health Records Meaningful Use and Public Health Virtual Event At this time the link we are about to send all of you is for anyone who needs Closed Captioning Otherwise, you can minimize the pop-up box you are about to receive My name is Sundus Adhi and I'm pleased to serve as your moderator today As part of CDC’s efforts to provide you with timely topics and expert speakers, we have with us today a panel of national experts who have kindly taken the time to share their views with us regarding EHRs particularly focused on Meaningful Use & Public Health Data Exchange Review of Agenda We have very exciting presentations lined up so let me briefly walk you through our agenda this afternoon As you can see on your screens, first we have Dr Art Davidson, speaking to us about EHR Meaningful Use but what’s in it for public health? Then we have combined speakers, Jeffrey Johnson, Robert Wester and Michael Coletta talking about EHR Meaningful Use and public health- the local implementation perspective They will be followed by Travis Broome speaking to us about the past, present and future of Electronic Health Record Meaningful Use Then we have Jim Daniel talking to us about the implications and challenges of EHR Meaningful Use and public health data exchange Lastly we will have Jim Kirkwood and Dr Bryant Karras talking to us about getting ready for stage of Meaningful Use Before I introduce our first speaker I want to inform the audience that 15 minutes have been allocated for Q&A at the end of each session You may type your questions in the chat box and the speaker will respond once he has finished the presentation With that, I’d like to welcome our first speaker, Dr Art Davidson: What is in it for Public Health? - Dr Arthur Davidson Dr Arthur Davidson, a family physician, is Director of Public Health Informatics, Epidemiology and Preparedness at Denver Public Health He serves as a member of a Federal Advisory Committee: the Health Information Technology (HIT) Policy Committee to the Office of the National Coordinator for HIT He also serves as a board member of the National eHealth Collaborative and board chair of the Colorado Health Institute He is an associate professor in the Schools of Public Health and Medicine, University of Colorado Denver I want to thank the organizers for this conference and allowing us to have an opportunity to speak about Meaningful Use Today I’m going to speak as a public health community member on the HIT Policy Committee and also as a public health practitioner I hope to engage with my public health colleagues to focus on Meaningful Use opportunities as we see them While there may be some mention of stage 3, I really am not going to speak much about that aspect as we have so much to work on Stage and Stage I will try to restrict my comments to what has been established with ONC and CMS through Page of 62 rulemaking and not focus on what is going to happen You may see opportunities where I talk about local public health agencies but they represent local, state, tribal, and territorial so I don't mean to exclude anyone Today some of the things we will try to cover are the following: First, we will just try to give a little context, and then provide Meaningful Use definitions, followed by a conversation on what are some public health reporting initiatives going around the country Then we will talk about what the process of on boarding looks like and what it means to be part of a registry Finally, we’ll have some concluding remarks and then answer any questions the audience may have The first issue is to say that there is a problem on this slide from the organization for economic cooperation and development you can see that the USA spends more money on positive outcomes compared to many other countries and as you can see, we are getting less for our investments So in response to that as you all know there's been an effort going on around the country and especially with federal investment and one of the things was back in 2009 when President Obama signed this in Denver- the American Recovery and Reinvestment Act There were three key pieces of that which I think we should focus on One is the idea that there was going to be this HIT Policy Committee where Meaningful Use was to be described and then the recommended to two agencies: 1) the Office of the National Coordinator that was much more fully funded compared to what had happened prior 2) Also there was money put forth for the Meaningful Use incentive program that CMS was going to carry out the colleagues at ONC As you can see there's quite a bit of money that ONC received but the amount of money for Meaningful Use incentives is much greater than $2 billion and some projected that to be somewhere between $27B to $40B and so far we've used at least close to $10 billion in Meaningful Use incentive funds We will talk more about that What is Meaningful Use quickly simplified – it is use of a certified EHR in a meaningful manner such as e-prescribing There is a requirement that also some exchange of health information and that the Meaningful Use eligible provider and eligible hospitals have clinical quality measures If you're a Medicare provider you could get $44,000 if you bill at least $25,000 a year in Medicare cost and then with Medicaid you can get up to $63,500 if you had at least 20% to 30% patients of Medicaid insurance What were the priority areas? Here are the five: 1) Improve quality, safety, efficiency and reduce health disparities, 2) improve care coordination, 3) engage patients and families in their care, and the one we’re most concerned about in today’s call is 4) improve population and public health and 5) ensure adequate privacy and security protections for PHI These are the priorities that the policy committee decided would be important and these are the ones that the Meaningful Use work group went to work on and started to develop the measures and objectives As you can see in the slide here, the first phase of Meaningful Use was from 2011 to 2012, it was data capture and sharing The next phase with the finalized rule which came out this year is for 2014 to 2015 which is about more advanced clinical processes The final rule for stage three has not been developed and that's what we are now soliciting Page of 62 comments in this request for comment from the HIT policy committee for this CMS rule that would be promulgated sometime in the next year to year and a half That allows vendors enough time to build out the products to meet the criteria and measures So what are some of the measures that we see in Stage 1? I'm sure all of you are pretty familiar with this already that the ones in the lower right are in the menu set and that's the immunization registries and syndromic surveillance These are measures that would be applicable to an eligible provider but here I'd like to point out what's on the left side of the slide that has been highlighted In the core set of measures, those things that I've highlighted in bold and italics are vital signs, smoking status, demographics, and clinical quality measures As we talk more about this during the next half hour or so we will be able to look at these and say, how these apply more than to focus on these several things that are on the lower right that relate more to public health? So if we go into one Meaningful Use public health objectives are we can see from Stage that you had to have the capability to submit electronic data to immunization registries but you only need to that as you can see on the right-hand side you need to one test of that in Stage Or you needed to submit electronic laboratory reportable data but you only needed to test that one time also Finally, submit electronic syndromic surveillance data and that was all just one test Whereas if we go to the next slide which now will move us to Stage objectives and measures, you can see that those same things are on here now they are core measures and there needs to be successful ongoing submission So public health agencies are having an opportunity for successful ongoing submissions to use that data on a regular basis for these three core objectives in Stage In Stage there were also some menu objectives, the last one was the core objectives and those apply for Stage to hospitals but in terms of eligible professionals, they also could be submitting electronic syndromic surveillance data, but that's a menu item Then there's also the idea that you could report cancer cases and that also will be a menu item or that you could report specific cases to a specialized registry on an ongoing basis and I want to focus on this last one because that's where I will spend most of the talk about specialized registries and how there were several places around the country and our health department that's working on this most specifically We will spend more time talking about that last specialized registry category Where are we at? We've actually done pretty well as I mentioned The program has been going on now for about two years and these estimates from a report from CMS in November to the HIT Policy Committee and you can see that there are quite a few providers around the country since the launch of the program Nearly 200,000 providers around the country have been recipients of Medicare or Medicaid payments Just wonder how many are in your community and how you think about using what they are now collecting in their EHR They've been incentivized as you can see in this slide to the tune of nearly $10 billion so far Quite a bit and has gone out to hospitals and how are you expecting to use those new data sources in your communities? Page of 62 In addition to the Meaningful Use program, there have been efforts within ONC to promote greater use of these data by the public health agencies around the country Between ONC and CDC, there's been the effort to create the Public Health Reporting Initiative and there are two key things that have come out of that initiative: 1) An effort to harmonize the data element profile and 2) An effort around the clinical document architecture and implementation guide - this is what we hope to be a consolidated clinical document architecture that helps us achieve much more with one framework to serve many different public health use cases These two efforts have been primarily based on the Cancer Registry reporting standards that we have seen promoted in Stage that I mentioned earlier They are also looking at the national healthcare safety network which is recommended in Stage as another method for sharing information with a registry in this case, one that would collect healthcare acquired infection information Advantages to this approach are that it does not require any change to the current efforts around reporting for electronic lab reporting, immunization registries or syndromic surveillance, but it does provide a future path to reusable modular architecture for an extensive methodology that could be leveraged for current or future reporting needs, like a communicable disease case reports or chronic disease reports or products safety reports or birth and death reports All of those are different use cases that would be able to use the two key efforts above, the harmonize data element profile and this consolidated clinical document architecture The whole idea of this is to find more generic interoperability between EHR and public health surveillance systems What we think that is required for success? I think one of the things is what we are doing today – get CDC's leadership to support this initiative with pilot implementations to share the message to bring forth from full scale implementations and to promote and contractually encourage broad health department migration to the new approach of this reporting initiative ONC and CMS have been collaborating and have proposed rulemaking and tool building to assure that these products (i.e harmonize data element profile and consolidated clinical document architecture) are maximally aligned with ONC convened standards and interoperability framework Finally, I think local and state health departments and tribal and territorial should review and advise what they think about these things to CDC We need a strong local orientation for this advisement to CDC How Stage changes local health departments’ obligations and opportunities and we will talk a little bit about that in a second and how Stage may set a new foundation for Public health monitoring and I think that input is essential In Meaningful Use the RFU exclusions and one of the things that we will get to is to talk about on boarding but if the public health authority does not have the technical capacity or does not have the resources to support ongoing submission in Stage 2, an eligible provider may receive an exclusion Or if a hospital has to a few things to get to that point, they need to register to submit, they need to be in the process of testing and validation or maybe awaiting an invitation to begin submission and those things would qualify as “in the process of” and not necessarily be defined as an “exclusion.” Page of 62 Here are what we now believe are important steps, emerging processes for public health authorities in Stage for onboarding At first, the public health authority needs to declare, needs to let the community of eligible professionals, eligible hospitals, and CMS know what Meaningful Use objectives are being supported Then after that is done, the registration of intent needs to happen by the eligible professional or hospital - they need to register with the public health authority and indicate its intent to achieve a specific Meaningful Use measure Then the Public Health Agency has to go through and on boarding process where they might queue and register each of those professionals and hospitals for exchange and then receipt of the information How well each public health authority define ongoing submission criteria? Finally, the Public Health Agency needs to acknowledge that the professional hospital is achieving or has achieved on boarding and meets the criteria for ongoing submission So these are steps that public health agencies need to begin to think about As I mentioned this is not going to happen until 2014, but things that we as public health agencies at any of those levels might need to be able to say, we have a plan to make these happen This is just a diagram of what I just described In the center it describes again that you must register intent by a deadline, you must participate in the on boarding process, and you must respond to written requests for action So at the top of this on the left-hand side you register for intent If the Public Health Agency is capable than you continue down the path If they are not, then you get this exclusion and the professional hospital has no need to continue with that activity if their jurisdiction provides them with that exclusion But if they are capable then the Public Health Agency may ask for some actions and the provider needs to act If they've done it once and failed, then they get another chance to it If they haven't succeeded on a second round they will be considered failing in that Meaningful Use objective If the provider acts and is successful then the Public Health Agency will onboard If the Meaningful Use objective is met then you get your letter for attestation You can see there's this process - this on boarding process is being defined by many in the public health community This slide I borrowed from work that's going on within JPHIT, the Joint Public Health Informatics Taskforce So we have some challenges Now that we have to all that work to bring people on board and then we get all these data, we will be swimming in an ever deepening pool of data And often we have little technology to efficiently use data converted to available information, and I think there's a mandate as well to have our staff feel like we have a direct relationship with these new data so these are significant challenges that we will be facing as a public health community However the opportunities are great:  Harness resources for very precise decision-making to help improve population and patient outcomes  Ensure better organizational readiness and increase information to support our mission  Enhance access to relevant actionable information through reporting and dashboards  Better monitor the key performance indicators to make better informed decisions Page of 62 I think this slide helps me to think about this is that we have on the right-hand side personal healthcare and you can see the very bottom electronic health record There are providers out in a community and community residents that have a desire to connect to an EHR and allow that EHR somehow to move to the right where it serves population surveillance This is what I consider sort of the fundamental process of monitoring the population We have on the left-hand side, public health employees and public health programs that want to create what I call or what Gibb Parish and Dan Friedman called the population health record This is where the information exchange is taken from the EHR and it serves the population surveillance need and that in turn can go back to inform personal healthcare to a variety of mechanisms that are happening at some places in the country To think about this in a little more detail and to go back to that stage Meaningful Use specialized registries, the way that we are conceptualizing this in Denver is as such: an eligible provider has from their EHR created some sort of standard data warehouse So here we have at 12:00 a standard data warehouse and at 3:00 a standard data warehouse and somehow in the middle of the cloud there is a query service that allows us to a secure federated query that we ask a question and a standard way of both standard data warehouses in a secure manner and retrieve results That could be as you see in the lower left, public health has a secure portal to allow it to see this standard data warehouse at a provider or eligible hospitals site This is the way that we have conceptualized the work here in Denver and I’ll get into more detail about that In the meantime through ONC and its efforts to act on many fronts, one of them is the Query Health effort to actually build out this population surveillance and population monitoring tool and there are currently five pilots going on around the country: In New York City which is around chronic disease and reportable diseases and syndromic and disease There's another one going on in many places around the country through the work of Harvard Pilgrim and HMO Research Network called the FDA Mini-Sentinel with over 126 million covered lives being queried through this standard data warehouse for diagnoses, drugs, and procedures There's another one through the same group of Harvard Pilgrim supporting the Massachusetts Department of Health with a MA Leagues of community health centers and Atrius health and they are looking at influenza like illness and diabetes surveillance We have one out of the CDC, the BioSense that many of you probably are participating with in this cloud-based system and the recent funding for that Lastly there is Allscripts and MITRE group working on how the quality measure formats Something that's been proposed by HL7 as part of the clinical quality measures reporting for stage The our efforts around the country to produce results from the pilots to help us inform how we move forward both in Stage and Stage and how we get to what we call the learning health system or healthcare system through Query Health Activities Page of 62 I'm going to now focus on some of the activities going on in Denver One of the reasons why we focus on the specialized registries is that we received a grant, this community transformation grant, which is from the CDC and it is focused on heart disease and stroke for us and it is to promote healthy lifestyles especially among population groups who experience the greatest burden of chronic disease and it is really focused as well on targeting a reduction in health disparities It’s a five-year grant and this Community Transformation Grant (CTG) has put out over $100 million to over 61 states and communities serving 120 million Americans This is the context for us thinking about building out a registry in Denver In Denver we were focused on the national quality strategies, the cardiovascular disease priorities and here you can see there is a focus on the effective prevention and treatment The opportunities for success were around increase blood pressure control in adults, reduce high cholesterol, increase use of aspirin, and decrease smoking How would we monitor that over time? To that we would look for measures that you could take out of an EHR so the measures might be for someone over 18 with the ischemic vascular disease – what was their most recent blood pressure and was it below 140 over 90 or was there a low-density cholesterol less than a 100 or is there evidence of use of aspirin or is there evidence that they had smoking cessation services either medications or quit line referral provided to them In our community we look at this as sort of a cascade, there are people all the way on the left who our unaware of hypertension and all the way on the right who our fully engaged in hypertension care What you need to is take people who are out in the community and link them to care from the left-hand side to the center and then from the center move them over to the right where they are having more quality Some people may be unaware, some people may be aware but not in care We try to link those some may be receiving some care but not hypertension care, some entered some hypertension care but that lost a follow-up, and some may come out of care and we have people working at the local level their community health workers- trying to find them Once they get to the system we have patient navigators and clinicians and patients and systems to try to keep them in care and move them over to the quality side Here is an example with hypertension This is Denver health and you can see in this slide at about 3:00 there's the public health department where I work with my colleagues But there are many other pieces to Denver health, a 9-1-1 system, a hospital with about 20,000 admissions a year, trauma Center with about 3000 serious trauma cases, family health centers with about 350,000 visits for a quarter of all of Denver, health plan with 10,000 patients and regional care center, correctional care center, school-based clinic with 12 clinics, are variety of services that are provided all across the healthcare spectrum All of these exist inside of a Health Information Technology framework What I see this is maybe a little prototype of what we might expect to happen in a true learning health care system where information is shared between the various components It is easy for me to say that because it is all under one umbrella, we have one CEO and it is one information system, but the idea here is that there will be registries developed from a variety of Page 10 of 62 the Medicare providers who are participating in this project for public health only for the Medicaid It is a problem that everyone recognizes I'm not sure if there's a short-term answer to that question I think long-term people are interested in looking at that I will just keep going through some of these slides I see a lot of comments from people who are interested in the cloud service idea I will share my contact information at the end because I would love to hear from people looking to that Public health domains included in the Meaningful Use regulations have varying maturity levels For data exchange, that was definitely one of the issues we saw at the beginning of stage one I think everyone has really come to the table and learned what they need to We've got a really outstanding technical assistance team at CDC by Sanjeev Tandon, who works closely with all the CDC partners to make sure that they understand what is needed We already talked about the lack of transport standards and implementation guides This first bullet on the next slide - coordination of Meaningful Use activities across domains, I think this is going to become really important in stage two What we saw in stage one was that most public health authorities really focused on one of the Meaningful Use measures for their state both with eligible professionals and eligible hospitals whether it was syndromic or immunization So there was really only one transport mechanism, one infrastructure that needed to be supported for Meaningful Use Once we start talking about supporting a Meaningful Use infrastructure across all of the public health domains, including possibly specialized registry reporting in addition to the new cancer requirement reporting, it will be really important to make sure that those public health domains within the state are working together I will say the CDC is working very closely across domains, the immunization people talk to the cancer people all the time, they are talking to the syndromic and ELR people to learn best practices and lessons Hopefully, we will see some of the funding coming towards for states to be also be more coordinated across these domains as well but that definitely will continue to be a challenge that we will all have to work on Collaboration with the state Medicaid offices, I have talked about that and Bryant has brought up some of the challenges there We have like I mentioned, about eight states that have approved plans to get to some Medicaid funding for their public health infrastructure and we're working very closely with ASTHO and other groups to make sure the public health has clear guidance on what they can actually put into the state Medicaid health plan that has a good chance of getting funding One of the other issues I think is captured in the next two bullets that we saw in stage one The capacity to deal with the sheer volume of providers and hospitals asking to submit test data and now in stage two they will be asking to be moved into production as well to meet those requirements I think Meaningful Use is a very different driver for getting data submitted to public health It is aimed at providers that public health might not care about Public health definitely has priorities for the types of providers that they would like to on board For electronic lab reporting, it would definitely be important for public health to go after the large submitters before going after a smaller hospital that might be submitting 20 or 30 results per year On the immunization side, it's definitely more important for those to Page 48 of 62 go after those large pediatric populations and that large pediatric provider actually may not meet their requirements for Medicaid so they may not even be Medicaid or Medicare incentive provider as part of the Meaningful Use program There are definitely competing priorities and a huge amount of work that is being asked to be done on the public health side I think having the communications and working with the appropriate partners to make sure that there is collaboration across the domains and again, this is a place where potentially working with the health information exchange and even our regional extension centers could help make sure that we are all successful as we try to this work Local implementation guides, we've already talked about that one – the certification criteria for stage two, I think really does address most of those issues I encourage everyone to go to health IT.gov and actually look at these certification criteria for the public health measures Those were actually signed as final yesterday I believe We’ve had draft guidelines out for comment since October and they have since been signed as final test criteria We're running out of time, so I think I will skip through some of these we have talked about The testing and on boarding in stage one was definitely a major problem We came up with the “testing queue” methodology Now that we're moving into stage two and providers have to be in ongoing submission, we have the stage public health advisory group led by public health informatics Institute with representation from ASTHO, NACHO, NCER, ISDS, and state and local health agencies They're really coming up with some guidance and best practices for how we best implement stage two, just like the guidance we had around stage one I think that Jim Kirkwood will be talking a little bit about that in the next presentation We have talked about modular certification and transports I want to make sure that everyone is aware of the Meaningful Use public health technical assistance team to provide focused policy and technical expertise We can help identify best practices that have already been put into place to resolve similar issues and the team is very good at documenting the issues so we that can get you written materials on other similar issues that have actually been resolved We can bring together people from CMS, ONC, CDC, all of the projects at CDC, we can bring them together and we can get everybody at the table in a single conversation to resolve the issues A lot of times, the problems can just be miscommunications And so that team is really good at getting the right people together at the table to have one conversation to resolve the problem And if Sanjeev is on the call, he can tell me how many issues they have actually solved so far It's a huge number If you need technical assistance to address any of these issues you can simply send an e-mail to MeaningfulUse@cdc.gov with request for technical assistance in the subject line and they will immediately get back to and start organizing They will get back to you with an answer or organize a call to address the problem In addition to the MeaningfulUse@cdc.gov as a contact, you can also e-mail me directly at James.Daniel@hhs.gov We have about 10 minutes remaining so I will stop for additional questions I am not seeing any additional questions Sanjeev has told us we’ve had almost 200 issues resolved so far, we’re at 188 It doesn’t look like we’ve got any more questions so I will turn it back over to the CDC facilitators Q&A Q: Seth has asked a final question about comments on public health reporting for stage three Page 49 of 62 A: I think Art may have gone over some of that earlier but I will say that we have the current request for comment out for the stage three recommendations You can find information about that on the stage three recommendations on health IT.gov Those comments are due January 14 Some of the things that you will see in there as recommendations for stage three are bidirectional immunization reporting, potentially case reporting as part of stage three or maybe a later stage, potentially adverse event reporting in stage three or a later stage And the other measures have stayed the same They are still not a recommendation to ambulatory onto the core measure, the others I think either stay where they are or moving into core for things like cancer I think those are the major issues in stage three that you want to make sure that you review for your comments Again, my contact information is James.Daniel@HHS.Gov and you can also send questions to MeaningfulUse@cdc.gov and I believe all of the slides and recordings will be made available Q: Cancer reporting and specialty registry reporting, we are really aimed at what is currently going on A: Let's talk about cancer reporting first That was aimed at the physicians being able to report cases, not the hospitals being able to report the lab information, which is why I think they aimed that at the eligible professionals Specialty reporting was aimed more at giving providers credit for what they might already be doing, and I think the things that they thought were already happening were really on the provider side and not the hospital side Q: The FDA has an adverse event requirement, how is that different from what might be reported to CDC? A: If you look at what is in the proposal for stage three and potentially beyond stage three, that adverse event reporting is actually talking about electronic adverse event reporting to FDA It would be the same, just doing that in a more automated fashion out of the electronic health record Wendy has provided some clarification, Wendy Blumenthal from the CDC cancer registry program Hospitals report more than lab information for cancer, but they have a wellestablished method for doing so And many of them use their hospital cancer registry That was another reason why the Meaningful Use measure was aimed more at providers, thank you Wendy EHR MU & PH: Getting Ready for Stage Meaningful Use - Jim Kirkwood & Dr Bryant Karras Thanks Jim, great to have you with us This brings us to our final presentation of the evening Excited to have with us Jim Kirkwood from ASTHO, Association of State and Territorial Health Officials and Dr Bryant Karras from the State of Washington Department of Health They will be talking to us about getting ready for Stage of Meaningful Use This will be more of an interactive session with the speakers having a dialogue with each other and sure to keep the audience engaged With that I would like to more formally introduce our speakers: Page 50 of 62 Jim Kirkwood serves as ASTHO’s Senior Director of e-health, overseeing ASTHO’s work on public health informatics This includes providing technical assistance to state and territorial public health agencies on public health informatics and national health information technology (HIT) activities Prior to ASTHO, he worked at the New York State Department of Health providing technical assistance and capacity building to local health departments in epidemiology / preparedness planning Dr Bryant Karras is a Physician, an Engineer, and a Public Health Informatician for Washington's Department of Health He has a clinical, technical and practical problemsolving approach with a background in Biomedical Engineering, Internal Medicine, and Medical Informatics Dr Karras teaches and mentors Masters and PhD students at the University of Washington and has developed Informatics competencies, curricula and continuing education courses, both in the USA and internationally As Public Health Informatics Officer he supports the informatics needs of Epidemiology, Health Statistics and the Public Health Laboratories He leads the DOH cross divisional efforts to prepare public health for meaningful use and changes to public health practice that Statewide Health Information Exchange will bring The thing about what will be happening for stage two, public health agencies are really going to be thinking about quite a few things They will be thinking about a plan for the reporting period of stage two because as we have heard before, instead of just one individual test and then a follow-up, a pass could be a fail at the same time, providers and hospitals will be looking to send data for the entire public health reporting period What that comes down to is which types of exchange are going to be offered and how? Will HIE be used? A lot of public health agencies will be looking to multiple providers want to come online and try to pull together a bunch of different individual connections, point-to-point connections will be difficult Working with HIE if they are available to use and the Public Health Agency can get the data at once HIE will be useful to a lot of people They will need work on providers with registration and also work closely with HIT coordinator and Medicaid agency HIT coordinator about general HIT issues, working through HIE and also the Medicaid agency when it comes to working with Medicaid on Meaningful Use providers but also working with them hopefully if state public health agencies can access 90/10 Medicaid match There is also a big issue which we had work done, a lot of states have worked on about organizing internally and educating their staff so they truly understand what the implications are for Meaningful Use and what the implications are for multiple states Stage Meaningful Use includes new guidance on processes for public health reporting It includes a declaration for public health capabilities and when we think about these public health capabilities, it is going to be what a Public Health Agency truly can do, how are they accepting data, and then how will that be in a centralized repository of Public Health Agency repository information, which we have heard a little bit about before And a provider or hospital might be registering with a Public Health Agency to initiate ongoing submission and we will see a very nice demonstration of that from Bryant Karras, a slide set, from Bryant Karras, Washington Department of Health, on how they register providers right now for Meaningful Use and all the information they give out to them Page 51 of 62 Q: What is the deadline for Public Health Agency declaration? A: I don't think it has been made official yet but I am working on the assumption that for capabilities for receiving messages from hospitals, eligible hospitals, we are working on October 1, 2013 deadline for declaration and for Eligible Providers and Professionals, we're expecting it will be the first of the year 2014 Public health agencies, the providers will be expecting to work with a Public Health Agency for the duration of what is going on There's also something in the Meaningful Use regulations stage about written request from public health agencies, that you give written requests over a certain period of time and if the provider or the hospital does not respond to the Public Health Agency, then the Public Health Agency determines they have not met Meaningful Use No Public Health Agency would want to get to that point with a provider or hospital knowing that the provider of the hospital has to meet all the objectives within Meaningful Use, equally and if they miss one, they miss all of them for their incentive And then there's acknowledgments to the eligible providers and hospitals about requiring some type of communication from the Public Health Agency that a provider was able to submit relevant public health data to the agency Which means, and this is another issue that came out from proposed rule from CMS and ONC and then the revised rule One of the concerns about the original notice of proposed rulemaking stated that they expected the Public Health Agency to a written communication to the provider at the hospital A lot of public health agencies and programs and associations have commented that we would like to determine what that communication is looking like You can imagine trying to send out a letter on the state or local Public Health Agency letterhead each time would be very difficult Whether it’s going to electronic communication acknowledging the submission and the receipt of information that is useful for public health, it will be determined by the Public Health Agency and in this case for generally, the Meaningful Use stage two rule itself, a lot of comments that public health did make were very public health was very successful in getting their comments included and considered in the final rule that came out One of the things that has been set up and this is done with ONC, CDC, and CMS also, is the setup of this Public Health Reporting Requirements Task Force Some of the activities of it at least was started at the last in person meeting of the Joint Public Health Informatics Task Force that met and was discussing these issues about Meaningful Use How exactly what will happen when a provider or hospital is looking to find out what a state or local health agency in their area is going to be doing to send Meaningful Use Who is that they send to? There've been a lot of associations, Public Health Agency involvement, CDC Immunization Registry community, ASTHO, NACCHO, and a lot of other CDC specific programs too looking at what’s going to be happening Looking at the public health declaration process, and the reporting requirements task force we look at certain focus areas or work lanes that have been set up for these groups And one of these have been the declaration process and declaration this is process by Public Health Agency of saying exactly what they are ready for in this CMS repository of information public health agencies Business processes trying to streamline business processes on registration of intent, on boarding or provider or hospital to be ready to work with the Public Health Agency, and business processes on acknowledgment of ongoing submission And then Page 52 of 62 there is been a couple other work groups that people wanted to set up on transport and specialized registers Some great work has happened through the support branch at CDC along with grantees of IAS support branch and immunization registries, looking at what transport is useful to for immunization registries, that will be useful for the future looking at bidirectional exchange and hopefully this group will be building on that and hopefully using a lot of that input that is been included in there And as we talked about, it leveraged some of the work that have been done during the previous meeting that happened in October of this year This all started because of this new rule and the discussion and when looking at the Meaningful Use final rules, you always have to remember that there is a rule itself in a discussion of the rule that talks about the implementation of rule and provide some clarification of the rule When you're looking at the rules as they are developed, remember to go back and look at the clarification too Again, to clarify the timing issue the hospital must determine if the Public Health Agency has a capacity to accept electronic data using specification prescribed by ONC for public use within the first 30 days and looking to the second underlined area and determine whether the Public Health Agency has a capacity CMS anticipates developing a centralized repository for this information including deadline for the Public Health Agency to submit information If the Public Health Agency fails to provide information in this repository by the deadline, the provider could claim an exemption or exclusion not an exemption, an exclusion to that particular Meaningful Use objective When we think about the declaration process, it’s a process associated with CMS repository and again as we said they will have to declare what they are getting the public health agencies providing objective readiness data into the repository so a provider can look at it and understand who they will be reporting to And thinking about what the implications are, they have to populate it by – they have to say publicly what they will be ready for They will have to declare that they have the capacity to bring on providers They will determine the provider types to support the objectives and if they don't provide that information, there will be an exclusion The public health Meaningful Use declaration process requirements recommendations: There are a few, recommendations that the task force delivered about requirements and recommendations for the declaration process to the CMS, and while those recommendations were included, there is no guarantee of what is actually going to be in the final repository that a Public Health Agency could use Some of the general things that people included, was to allow that the Public Health Agency to declare readiness This is important because in a couple of states, and a couple localities you could have requirement for a provider or hospital to report to a local public health agencies for one item, say immunization, and then to another one, say for electronic lab reporting There could be some confusion on the provider level of who exactly they are reporting to Also, it should only contain information on public health agencies that provide readiness Meaningful Use objectives will support Meaningful Use objectives will not support and that information has to be available for hospitals by beginning of October in 2013 and by providers a month before December of 2013 Which is only a year away Some of the other requirements would be public health agencies should be able to validate information in a centralized repository prior to publishing so they can see what is Page 53 of 62 being submitted CMS should be able to communicate with the providers, with Public Health Agency before the deadline Identify public health agencies that have submitted data to CMS And again a declaration will be for the fiscal or calendar year but we hope that a Public Health Agency should be allowed to update their readiness throughout the calendar year This is really important for those public health agencies, we have seen this with stage one were a lot of public health agencies thought they would be ready and could get ready for Meaningful Use stage one but they found out that they had to go off-line for a little while and come back on after some period of time because just getting ready Declaration should be made by the public health authority If you're going to be requiring public health reporting, the public health authority has to be the person whether it is state or local level that is determining we can require this of the provider or hospital That have the legal authority and the objective say particular public health practice And finally one of the things we wanted to encourage though it is not required, you can imagine the difficulty of this, encouraging the state and local public health agencies within a particular state to determine and say this is exactly what we are ready for And then come to an agreement on the state has the authority here, all the data should go somewhere else or another That’s some of the things we included Some of the requirements and recommendations on specifically the data elements that you should be supplied about public health readiness, Public Health Agency contact information, not necessarily going to be an individual with their particular name but it could be MU@StateX.gov and then also transport, what method of transport is being used to support Meaningful Use for that particular objective? It's important to think about that, as public health agencies start to think about how we deal with healthcare data in our state, how we want to streamline the processes for reporting for states? And then the date and time The date and time the PHA can technically receive data and accept data In conclusion, the repository would allow providers to more easily locate public health agencies and that has been a concern of providers and vendors especially when dealing with providers and to help the provider meet their Meaningful Use objectives Again, it could provide some standardized information about public health capacity that a provider or hospital, depending on who they report to - the state or across systems across states or systems within a state across boundaries can really look to and see what is the truth Business processes for stage two, next steps are works in progress are about registration of intent of the provider How would that work in dealing with the state or local Public Health Agency? And how would the on boarding process go? What is that really going to look like? It's important for providers to understand they can't show up on day one and then be meeting Meaningful Use for stage two on day two And we talked about some guidance documents, communications going out and special workgroups on transport and these other registries that are really undefined in stage two of Meaningful Use One of the things I want to talk about quick before we get onto the description of these really nice websites that are out there is working with Medicaid We had talked a little bit and heard that throughout the session today about the 90/10 match for Meaningful Use It is cost allocation which means that it is a percentage, as you can imagine, there is a percentage for Medicaid if it's acceptable to CMS The activities would include 90% Page 54 of 62 reimbursement of the cost for Medicaid providers or hospitals You can imagine if there are within immunization Registry there's activity going on that might be acceptable to CMS, they would reimburse 90% and say 40% of kids on Medicaid in that particular state or that particular locality As Jim said, there will be guidance coming out hopefully soon about what exactly is acceptable I think a lot of states have applied and those have been accepted for something hasn’t been quite clear to them as to exactly what would be successful And even the states that are hearing things now are still trying to figure out what exactly will be successful and what is a viable option for public health funding We've heard from presentations of what has been successful up to this point Supporting a single gateway to public health Meaningful Use system, so if there is some state trying to implement a universal public health node, whether it is through HIE, CMS has indicated they have been willing in the past to allow funding for that And also on boarding of providers and that would be specific to providers that are involved Medicaid providers, not necessary Medicare providers Another important thing I think people have done in Meaningful Use, and these websites have really evolved over the past year or so are these websites that really communicate to a Public Health Agency Everybody knows that the people communicate and Bryant below has showed a shorter URL for Washington state down below (www.doh.wa.gov/healthIT), so feel free to click on that because that is one of the websites we are going to show you in a couple screen captures But we also have some very nice ones for Maryland and Nebraska Department of Health and Human Services as well What are the things that people have been happy with when they have done their website? The big thing is being very specific They are specific about whether Meaningful Use is ready and they even include a date of readiness (i.e “As of December 18, 2012, we are accepting new providers for on boarding for immunization.”) And you'll see those on a few of these websites They are explaining what transport mechanisms they are using and for which objectives, and they are saying which accepted message format is used HL7 2.3.1 or 2.5.1 and they are also providing contact information for a person or for a general Meaningful Use public health at the state website or at the state domain name And also, in the case of Washington State, they even included very specific steps in the process and the length of time it will take for onboarding We've seen those for a lot of the immunization registries while there might be an implementation guide specific for the state, they will also include more guidance for the state on exactly what is going into this process of submitting data electronically to the state via HL7 message which is great As we said, you really don't want providers or hospitals coming to you one day before the beginning of the reporting period and expecting them expecting to be on You want to be as upfront with them as possible so they understand they need to be ready for this process very early on This is Washington state's website and after I go through this quickly we’ll have Bryant talk a little bit about it You see they have six steps of enrollment to production And what they have explained for electronic laboratory reporting on boarding process Very specific, they will tell you exactly what they're doing Then they go to the enrollment and they have an enrollment form, and they say again, if we look around at the bottom here, this is the HL7 2.5.1 ELR message and it must come from a certified health IT product Behind that there is a definition of Page 55 of 62 what those products are and then on the enrollment form, they're asking the hospital in this case to say, which objectives are you working on, what stage of Meaningful Use are you working on, and later is when we get toward in stage two there could be some providers trying to meet a different stage of Meaningful Use and which quarter they expect to be a testing And they ask for their information NPI, etc Can you hear me okay? Looking back of the previous stuff enrollment now with official terminologies, I will have to turn that into “registration” since that is the term that seems to have matured We worked on this webpage six months ago The terminology has evolved, but one of the most important things that we did was put that question in on what quarter are people planning on doing their attestation So trying to get providers and hospitals to think ahead and give us advanced notice of when they're going to be working on it for our planning purposes so we can know how many people we will be needing to the on boarding with during a given month or given quarter The first year of stage two will be particularly it will be different from the rest in that it is a 90 day window that people are doing their ongoing submissions They may not all hit at October 1st but when they hit, they will expect to be engaged and are going to want to be on board and in production and interacting with us in time to make their attestation One of the other things I would like to point out, on this page and the next page is that Washington is really relying on some of these national activities that have been out there like the reportable condition mapping table so the hospital can see the SNOWMED codes used for reportable conditions In the pretesting phase, if you go back to the pretesting, we ask that they hit against the MQF and then actually present to us their reports on how they did against the MQF So they are essentially getting some feedback, pre-feedback without the state actually having to go through a message – looking at the HL7 message to see that, is it totally gobbledygook, or useful, and you want to get to that baseline level so the Public Health Agency can really work with them and put some time in with them In testing, they're talking about the different types of transport mechanisms that the Public Health Agency is going to use, and then going into further they explained, what Jim had talked about just a little bit in his presentation And in your case Bryant, you wanted to be upfront with them about being in queue Can you talk about that a little bit? One of the things that is still very true, there are subtle differences in the six steps between syndromic surveillance and ELR They are not exactly identical but we try to make them comparable so that a given provider who is going through both at the same time understands the terminology and can navigate through it In terms of being upfront with them, one of the things that we ask several questions on page two and page three of the registration or enrollment form, we ask information about their patient volume And we are upfront about we use this information to case-by-case selection of how quickly a given provider moves through a queue If they only see 20 patients a day and they are in Page 56 of 62 private practice, they will not move through the queue as quickly as a group practice that sees 5,000 patients a day because from our standpoint it is the same amount of work for that on boarding, so we need to make some decisions about prioritization I think this may change some when we get to there's a question that we will have to add to our on boarding questionnaire If we receive the 90/10 matching funds we will ask if they are a Medicaid provider And if they are a Medicaid provider, we may have special support funds from 90/10 matching which will give us access to additional on boarding staff, and we may be able to prioritize them but I think it will be interesting to see what happens in stage two with all these changes And last thing I would like to note is that when you have someone in queue you are affirming to them that you will be submitting during your normal way of reporting whether it is via fax or phone or mail for the normal reporting requirements for the Public Health Agency to ensure that the Public Health Agency doesn't lose data it would have gotten through the some boarding process That is the point you're trying to make Absolutely One of the misinformation that we don't want to foster is that once they have made the connection, they are done The most work intensive piece of this is the validation - the work of comparing that paper message via fax or what have you against the new HL7 message And that validation process actually involves workflow all the way down to the local health jurisdiction department Who in our state, the home rural state is actually the acting entity, and we work very closely with the local health jurisdictions to validate that they are just as happy with the new data stream as they were with their traditional reporting mechanisms before we tell the providers to turn off anything We will move on from discussion of the Washington State Website on boarding website to some general discussion about Meaningful Use and I think at this point it would be great if the people that are still on out there can e-mail their questions or share information on how they might be doing something to prepare their state for Meaningful Use Q&A Q: One thing we talked about mostly was education at the staff within the agency Not always think about Medicaid or Medicare How did you educate them? How did that go within your Department of Health? A: Education within the department, one of the things that we got a little bit of a jump on is that I've been tracking this since 2008 and 2009, and started making presentations to leadership at the department about what was coming, how we needed to get ready for it, and perhaps as a result of jumping up-and-down, warning people that the sky was falling, they put me in charge of Meaningful Use for the agency Be careful what you wish for I was put in charge of creating a cross divisional Meaningful Use workgroup and gathered people who I projected might be affected by Meaningful Use I was pretty accurate in getting the right people on the group We have a couple of people who didn't make the final cut for stage one that got involved early, but it was still helpful to have people all Page 57 of 62 across the agency participating because they could anticipate what was coming in stage two, and ultimately in stage three It wasn't having to re-educate the agency Another important thing we did was that we created not just educating and informing, we pulled together the decision-makers from each of the different divisions, the Chief administrators and assistant secretaries that ultimately had decision-making over these programs, and kept them informed of what was coming and gave them the ultimate say so on the priority list of what gets connected to the health information exchange and how we designate what we are ready to for Meaningful Use Workforce education is a huge thing That is something that everybody is clamoring for and there is a separate workgroup generated that is trying to move forward on this We engaged with Bellevue College, who was one of the ONC recipients of training dollars They were the head for the entire northwestern region, multistate effort to retrain displaced IT workforce And they created a 10 week certificate module that we had 40 of our IT staff go through that gave them the 101 and 102 education on what is Meaningful Use, what is health IT, and gave them a lot of the building blocks to really ready our agency for this And then we received a question The question was about whether the Supreme Court decision on ACA this summer affects Meaningful Use at all and it should be clear that Meaningful Use is from the HITECH Act which is the American Recovery and Reinvestment Act commonly known as the stimulus Two very separate things Q: One of the other questions that we wanted to ask about also was how is your department working with HIE and the Medicaid agency? Good mentioned you were looking to apply for 90/10 match funding A: We are working very closely with our sister agency, and Washington state, the Department of Health is not the same department as the department that runs the state Medicaid program That is our Washington healthcare authority It is coincidently now after reorganization the same agency that is the state designated entity for the statewide HIE They have at least the ability to coordinate with themselves on those two fronts But for the public health measures, myself as the informatics officer and this coordinator was designated as liaison to the healthcare authority Working with them on coordinating our -a common message so that we have unified messaging coming out from both agencies about what providers should be doing for Meaningful Use And then I am working very closely with them on an IAPD, Implementation Advanced Planning Document, that Jim Daniel mentioned in his presentation Which allows a cost allocated 90/10 match request for activities Working with our state HIE, one of the first things that we are targeting is electronic laboratory reporting Our HIE is already up and running in Washington state and one of the first things that they prioritized were laboratory results It was a logical follow-on to have electronic laboratory results to public health be a prioritized message type that we get transport to us through the HIE The logic there is that by using the state HIE instead of investing in point-to-point connections, we can focus on the harder work or the more complex work of validating the contents of those messages, and have the HIE work on the nuts and bolts of the of transport of those messages So it is a nice division of labor there Page 58 of 62 Q: A few states have been asked to there was a letter from Dr Friedan a couple of years ago or maybe a year ago from the CDC to state public health officials and others about designating a Meaningful Use coordinator within a state, that’s going to have a policy level responsibility for coordinating and implementing Meaningful Use within the state Has Washington State on that? A: Yes, we did That was me And I think in a couple of the CDC – ELC grant asks for the informatics designated point person There is some convergence across the CDC Not just from the upper leadership, but I think that one of the things that it has done in our agency is instead of just focusing on areas that have traditionally interacted with CDC on informatics issues or infectious disease programs, this Meaningful Use attention has elevated the necessity for the court nation across the agency And they changed my title from informatics officer to Chief Informatics Officer so that I had responsibility to coordinate across the entire organization, not just the division where most of the work had previously resided Real important thing Q: Can you talk a little bit about communications between from the Public Health Agency to the providers in hospitals and how that has changed over time? A: In the early days, it was mainly myself attending informational meetings that the health information exchange and the healthcare authority and our state designated entity were hosting with providers This is back in the time before the HIE was even active And getting information out and dispelling myths in many ways aecause people assumed what their vendors were telling them was true - that most Department of Health can these messages And it was getting the message out ahead of that, saying yes we are able to receive all three message types in Washington State, and communicating that More than two years ago, we got up a webpage, the one I shared with you, at health IT, we also have a webpage that is joint between all of the agencies in Washington that are affected by Meaningful Use and the HIE and it has links to each of the different program areas That has done a lot to drive providers to accurate information, rather than myths and misinformation In the last three months, four months now, we have created a communications plan with the healthcare authority, or we have walked through what are the key messages we want to get out to providers either on the hospital side or eligible professional side And using that template of message has allowed them to give a consistent message and us to give a consistent message and we have told our webpage around the framework of that communications planning document And that has really helped us to have coordinated efforts in this path I can't believe we are not getting any other questions Q: We got a question from Bill Brand from the public informatics Institute Was Washington State able to consolidate around transport across all Meaningful Use programs and other programs as well? A: That is an excellent question, Bill You're asking it because you know that is a very difficult one to solve At the moment, our plan is focused on our plan is focused on two message types that we are consolidating the transport between One is outgoing message, newborn screening, which is not part of Meaningful Use but was one that was completely under the control of the Department of Health We used it as a test case for interacting with the health information exchange Since we're the ones that generate the Page 59 of 62 message, we didn't have to coordinate with a partner on it That one is exclusively going out through a pipeline to the statewide health information exchange If a provider wants to get rid of their paper envelope, newborn screening message, their only solution is go through the HIE and the secure channel that that enables I just saw another related question, that I will answer right now We are hoping that newborn screening is part of the consolidated CDA and will be part of stage three At the moment, we are following the NLM 2.5.1 message type for newborn screening We should note, so that we are talk about Stage and will it be in there, the comments are due on January 14 If there is interest in newborn screening be included, feel free to comment that to the FIT policy committee The inbound we are looking at ELR is the first one that our senior leadership has approved and makes complete logical sense to migrate to using the health information exchange and using the same single catcher’s mitt or umbrella to catch inbound messages coming to the Department of Health That message type is very similar to newborn screening in many ways Although it is an inbound message coming from other hospitals, not our own LIMS system sending an outbound Those two are going to use the same mechanism and the same message handling queue or message queue management within our agency A real tough question is looking beyond that Will we use syndromic surveillance through the same mechanism and will we use immunization through the same mechanism? Both of those systems have a history, a legacy of point-topoint connections in our state It is going to be a little bit more difficult transition, replacing those point-to-point connections with the new, unified entrance point for the agency In terms of sustainability, it is really the only logical approach We estimate that it takes about half an FTE to maintain every 14 point-to-point connections to our agency And in stage two, if all of these communications become core and required, not optional, we are going to have hundreds if not thousands of people requesting to connect to the agency and the only sustainable mechanism I can see is to take advantage of using the statewide HIE to bundle those transport of those messages Q: We see question from Seth Foldy who asks will health departments be able to find a toolkit or central site to prepare for Stage communication with eligible providers? What is going to be out there for public health agencies to use in their communications? A: Something that we could and others whether it's ASTHO or the other associations that are involved in one of their systems like ARRA and CST and others is to provide those best practices that are out there for committee getting with hospitals and eligible providers about Meaningful Use For stage two, CMS has some very good tools out there and checklist and other things about repairing for Meaningful Use But when it comes to reporting to a PHA, the information about the central repository that we talked about will need to be included in any kind of toolkits that would be out there Q: Any sort of advice you have for states or lessons learned in preparing for Meaningful Use that jumped out at you? A: Three quick things in the remaining four minutes Page 60 of 62 If you haven't already done so, find some poor person who is willing to be your Meaningful Use coordinator It is helpful to have someone with vision about how this will work across your whole agency and make sure that person communicates across program areas that are both currently affected and will be affected in the near future Cancer registry is one that came up in discussion earlier You need to invest in your staff Make sure they get the support for this crazy amount of work that is coming their way Whether it’s online training, reassurance of how critical they are as you go forward year-to-year budget so you don't lose them to better job offers Do plenty of planning, especially around communications to get out ahead of this Work on your webpage and work on automating as much as possible this onboarding process in terms of the registration process because in the early days of this work, I was in the critical path of all messages People would either call me or e-mail me to find out what to next It went from one message a day to multiple messages a day You need to very quickly try and automate as much as you can so you can get one person out of the critical path And still have electronic documentation you can use to start making education about how people get on boarded Q: We received another question from Ashley Dixon You mention this use of the state which HIE to better manage and produce connections but in Texas, they have 12 local HIE's across the state That seem to be different levels of maturities and what suggestions you have in this particular case? A: One comment was that we received from ONC was that in the Public Health Agency, seeing this working possibly as a network of networks model A state the size of Texas or the size of California trying to network those networks that exist together and also a Public Health Agency should consider that those 12 connections with the HIE will be better than the thousands of point-to-point connections that could be existing if all providers wanted to get on or on the hospitals want to get on Do you have anything to add Bryant? Especially in states like Texas or California, where the population is such that a single state HIE may be overwhelmed onto itself I agree, 12 is better than thousands But I think that wherever possible, in our state for example, our statewide HIE will bring on a regional aggregator Some of our long-standing regional health information organizations are joining the statewide HIE as an aggregator so that the statewide HIE becomes the networker of networks So wherever possible, look to working on simplifying your process Q: Barb Weathersby, on Washington's website and Barb I don't think I should let you ask questions about Washington's website I am still mad at you In step four in queue eligible hospitals who have successfully submitted qualifying test messages are placed into the queue Is there a maximum time limit for it to be in queue before the validation process starts? This is a great question We're out of time A: If Jim is still on the line, one of the things that ONC did was create the in queue process Which allowed in stage one allowed us to get people into the queue of testing and that enable to attestation For stage two, we are treating the on boarding process as a whole and once you are in the queue, as long as there is no nonresponsive Page 61 of 62 interaction between the two parties, we are treating that as they are still online and still actively working on to production Hopefully there is no time limit That allows us to prioritize where we have the resources and who we can work with first Thank-you Bryant Thanks for joining us on this Now we will turn it back to the CDC Concluding Remarks It is now 5:30pm on the east coast, which means we are at the end of our virtual event We are thankful to all our phenomenal speakers for taking the time to share such valuable knowledge with us today And we thank our audience for joining us and hope you all benefited as much as we did I just want to let the folks on the call know that we will be posting the audio and transcription from today’s sessions on our website at www.cdc.gov/ehrmeaningfuluse/ , so look out for that Also, if you have any questions about our virtual event, please email us at MeaningfulUse@cdc.gov Once again, thank-you and good night! CDC Event Coordinators Dr Sanjeev Tandon, MD, MS - Content Design & Outreach Adam Arthur & Scott Wilson -Virtual Platform Anthony McDonald – Communications Sundus Adhi – Event Moderator Page 62 of 62